Why the Tories and Reform are not serious about Wales
Plus we reveal the 20 year scandal that few people know about
Reporting by Will Hayward and Ryan O’Neill
Hello and welcome,
The first half of this newsletter looks in detail at one of both the Welsh Tories and Reform’s only consistent policies. We show how both these parties are deeply unserious about actually improving Wales.
The second half of this newsletter is something that we are really excited to bring you. It may seem technical but we have been looking into an absolute scandal into how a critical part of the Welsh NHS has been funded. It is genuinely unbelievable.
Before we start, I want to talk to you about Hello Starling.
Those of you who have been with me since the start will know all about Hello Starling. They are media planning and buying specialists. But what does that actually mean?
Well let me give you an example of what they do. They ran a digital campaign for Visit Warwickshire which led to in excess of 1.9 million people being reached amongst specific audiences.
To see how they can help your organisation visit their website here.
Why Welsh Tories and Reform are utterly unserious
With the election now fewer than 100 days away we need to start looking at policies. Ahead of May we have already had plenty of rhetoric, but across the board we are short on policies, meat on the bones and detail.
Given that the Tories and Reform are currently projected to make up a third of the votes in Wales, it seems fair to ask what they would do if they were to get their hands on the levers of power?
The problem is that they don’t have much in the way of meaningful policies at present. This makes it hard for us to scrutinise them. Luckily there is one policy that both Reform and the Tories have been consistent on - “scrapping Labour’s 20mph speed limit”.
The Welsh Conservatives in particular have been relentless in their opposition to the 20mph policy since they came in (though as you will remember they were widely in favour of it previously). You might say it is their flagship policy. When it comes to Reform, they have barely said anything about Wales and 20mph is the only meaningful Welsh-specific policy I can find about them except vague statements about reopening coal mines (scrapping the Nation of Sanctuary doesn’t count as it is totally insignificant from a financial perspective).
If either party are actually serious about governing in Wales and improving the lives of people here, one would hope they would have given thought to one of the few policies they actually have. So let’s assess!
What would “scrapping 20mph” actually mean?
Though ditching the 20mph limit might sound like a simple thing, in reality it really wouldn’t be. Since it was introduced in September 2023 it has reduced casualties by a third and saved £43m in just its first year. It has also reduced insurance premiums by about £50 in Wales compared to England.
I therefore approached both parties and asked the following questions (I have explained why we asked this under each question):
1) How will this policy work in a practical sense? Will all roads that have become 20mph simply be changed to 30mph? Will there be exemptions and will these be conducted by local authorities? When the 20mph policy was introduced, councils could exempt certain roads. I was curious about how the Conservatives and Reform thought this would work in reverse.
2) Will people who don’t want a 30mph limit on their street be able to appeal it? Polls suggest that though some people really hated the change, many were very much in favour of it on their particular street. If people in an area didn’t want the limit to change back I wanted to know if either party envisaged a mechanism for dealing with this.
3) How do you anticipate this will impact car insurance premiums as a result of this change? Surely they have a plan to mitigate the impact this will have on people in Wales during a cost of living crisis?
4) How much do you estimate this policy change will cost (signage, messaging etc)? One of the big criticisms of the original policy was the cost of changing all the signage over in Wales. This was about £40m. However, this was a one-off cost. It seems likely that the cost of changing it back would cost about the same again. Given their vocal opposition to wasting public money you would hope they would have thought about this.
5) How will you approach the impact on the NHS arising from moving to a 30mph speed limit, given the reduction in road injuries since the 20mph policy took effect? Have you modelled how much this will increase casualties? Ultimately, this policy was about reducing the number of people, particularly children, hit by cars. It has been very effective at this. You would expect any politician who is serious to have thought about whether what they are promising will result in more children dying.
6) Under this policy will roads that were previously 20mph also become 30mph? There were many roads in Wales that were already 20mph before the change. I wanted to know if they planned to change them too.
7) You have previously indicated that you are in favour of 20mph around schools, care homes, parks and busy pedestrian areas. Will it remain in these areas? If so what will the distance be from these places where 20mph will remain? When questioned previously about 20mph the Tories and Reform have consistently said they are in favour of it in areas like schools, care homes, parks, doctors surgeries and busy pedestrian areas. Given that you can barely go anywhere in towns and cities without passing these things, we wanted to see how this would be applied practically.
Their response
Not an unreasonable set of questions you might think? We put them to both Reform and the Welsh Tories.
The Conservatives sent us the following response:
“We have always been clear that we support 20mph limits outside schools, hospitals and places where there is a safety argument. However, we do not support the default 20mph limit across Wales. We would restore it back to 30mph.”
Hmmm. Not exactly a comprehensive response is it? I went back to them and said:
“Just to be clear. I will be publishing the list of questions I put to you as well as your response.
“Given this is one of your key policy pledges I just want to give you the opportunity to put more meat on the bones if you want to.”
To this I got no reply.
Clearly they didn’t really answer most of our questions but they do at least attempt to answer question 7 by saying:
“We support 20mph limits outside schools, hospitals and places where there is a safety argument.”
But even this poses more questions than it answers. Saying you support 20mph “where there is a safety argument” is nonsense because the entire argument for 20mph is a safety argument.
Just to show how impractical their plans are, I decided to pick a part of Wales at random and plot all the carehomes, schools, hospitals, doctors surgeries and parks on it.
I chose Bangor and every car on the map below shows those places:
Bearing in mind that this doesn’t include busy shopping areas, high streets or residential areas etc, there would be far more places staying 20mph than there would be changing.
Reform UK didn’t even reply to our multiple messages.
Utterly unserious people
Let’s face it, we know why the responses from both parties are thin or non-existent - because they haven’t really got a plan. They have found a policy position that they think will win votes and are just repeating it ad nauseam with no real thought to how they would actually deliver it. It is the mark of two utterly unserious parties. In the Tories’ case they have given up on any idea of winning (if they ever had it in the first place).
Their relentlessly pathetic excuse for political opposition does as much to contribute to the terrible governance of Wales as successive Welsh Government failings. When this is the standard of opposition, is it any wonder that those in power can afford to be so abject?
The scandal that’s been ignored for 20 years
What we are about to talk about seems fiddly, complex and hard to get your head around. So before we explain it, let’s put it in really simple terms.
There is a funding formula for GPs that has been used in Wales for the last 20 years that:
Is totally unreflective of reality.
Initially punished GPs in Wales compared to those in England.
Was designed to reflect England’s demographics and not Wales.
Guarantee that GPs in poor areas of Wales will be worse off than rich areas.
This is baked into the system. A system that the Welsh Government could have changed at any time.
But as we have looked into it we think there is a wider story here. Because no one really seems to properly understand why we have got to where we have.
So let’s dive into this. It will be complicated but it is vital that people understand this because it is so often the very opaqueness of these issues that allows them to continue.
How are GP surgeries funded in Wales?
Funding for GPs is managed by the Welsh Government and GP practices are contracted by their local health board to provide services.
GPs are funded in a few different ways but the bulk of their money comes from the Carr–Hill formula. This is a method introduced in 2004 to allocate funding to GPs based on the demographics of their patients and other factors. It is used by both the Welsh and English health services.
It is based on six components:
rurality (how far away patients are from their GP)
patient age (for example, older patients and young children tend to see a GP more often than a working-age adult)
additional needs (things like long-term illness and overall illness levels)
list turnover (how often patients move in and out of a GP)
numbers in residential and nursing homes
local staff costs (how expensive it is to run a GP surgery in this area)
The way this works is that the data for each patient who is registered at a GP is looked at and given a score or ‘weight’ based on these components. They then create an overall score for each GP practice based on how much workload their patients are expected to generate. This is what is used to calculate how much money that GP gets.
For example, if a GP practice with 10,000 patients is weighted 0.8 they would be paid as if they had only 8,000 patients. If another GP with 10,000 patients was given a 1.2 weight they would be paid as if they had 12,000 patients.
In theory this sounds fair. Some GP surgeries will have patients who are sicker, older, more expensive to treat or who have to travel further. The Carr-Hill formula is supposed to address these different needs rather than just giving GPs money based on their number of patients.
But there are a few big problems. For one thing the Carr-Hill formula has barely changed since it was introduced and uses a lot of data that was collected between 1998 and 2001 - so some of it is now 27 years old.
This issue with this should be obvious but as an example of how bad it is, any housing development built after 2000 is literally ignored when it comes to the formula.
Two Cardiff GPs pointed out that the formula also ignores loads of really good recent data we have like disease registers, hospital admissions, frailty, lifestyle factors, home visits, and multi-culturalism that far more accurately predict healthcare utilisation.
It has also been criticised for not properly accounting for deprivation. We will come back to this because it matters a lot for Wales.
No one seems to be able to give a clear answer on how the formula works. We have been looking in detail at this and it is hard to get an answer. None of the GPs we spoke to, whose practices are funded by it, fully understand it either.
To illustrate this, let’s look at the example of the Welsh Tory MS Peter Fox, who is widely considered a thoughtful, engaged Senedd member. He is chair of the Senedd’s health and social care committee, previously held his party’s finance brief and has literally just become their shadow health minister.
In September last year he said this during a health committee meeting:
“I never even knew what the Carr-Hill formula was until recently, and I’m hearing more and more about it.”
The issue is in the details. For example, we don’t know how much extra funding an 80-year-old woman gives a surgery compared to someone younger or how local illness rates are translated into workload. GP practices are told their funding amounts but not shown the workings.
But there is more. Something happened two decades ago that experts believe had a massive impact on how GPs in Wales are funded.
What is going on?
Given that the most crucial frontline service in the Welsh NHS is funded by this, it is bizarre to say that no one seems to know how it works.
But some really smart doctors and academics have looked into this and think something happened with Carr-Hill that had a huge negative impact on Wales, especially straight after it was first introduced in 2004.
Dr Matthew Jones, a Cardiff-based GP, submitted a response to the Senedd’s health and social care committee inquiry on the future of GPs in Wales last year that covered this.
He wrote that after data from England and Wales was collected to be used for the Carr-Hill formula, the data was then ‘normalised’ meaning England GPs were only compared with England GPs and Wales GPs compared with other GPs in Wales.
Because GPs in England and GPs in Wales were not directly compared with each other this meant that straight after the change was made 2004, the average GP in Wales and the average GP in England got the same money.
This is a problem. There’s no way England and Wales should be treated the same when it comes to GP funding. Let’s break down why this doesn’t make sense:
Wales’ residents are older
Wales is more rural (it is four times more sparse than England, so patients have further to travel to see their GP)
Wales has a lower life expectancy
Wales has a higher proportion of patients over 65
Wales has a higher standardised mortality ratio (this is essentially whether more people are dying in a place, given their age)
Wales has a higher % of people with a limiting long-standing illness or disability
In his committee response Dr Jones cites a 2010 study that estimates the original formula for Wales was actually 10-12% higher than in England and that levelling out the numbers actually benefitted England GPs slightly.
GPs in Wales, on the other hand, lost 10-12% of their funding when they started being compared only with each other. He wrote:
“Consequently, General Practitioners in Wales faced the decision of either working 12% harder than their counterparts in England or accepting 12% less remuneration.
“To their significant credit, GP Partners in Wales have consistently opted to accept lower pay compared to their English counterparts.”
So this means that, initially, many GPs in Wales accepted lower pay to subsidise the backwards formula imposed on them and protect patients.
In a webinar last year on the topic Mr Jones said:
“virtually every single practice [in Wales] would be disadvantaged by this to a certain degree.”
Another key problem with splitting England and Wales is based around how rural Wales is. The Carr-Hill formula is financially beneficial for rural GP practices.
This was fine when Wales was simply a small part of the overall England and Wales data because Welsh cities are small compared to England’s and we are far more rural. This meant that big English cities like Birmingham and Manchester were being punished by the weightings to the benefit of Wales.
However when the formula was applied to Wales on its own, the fact we only have a few very large population centres means that those Welsh urban areas were disproportionately punished in the weightings.
This is an even bigger issue when you consider that of all the Welsh areas with the worst deprivation, more than 90% are urban rather than rural. We can see in the data even now that Cardiff and Vale health board has the lowest average GP funding per patient in Wales.
This leads on to the next point…
The worst part of this - the poorest suffer the most
So we know that Welsh GPs are getting a bad deal. But when you dig down into the figures in Wales it is much worse than that.
We need to look at a study where GPs and experts analysed more than 300 GPs in Wales and found something shocking:
